UNITED STATES PUBLIC HEALTH SERVICE 

RUPERT BLUE, Surgeon General 



THE PHYSICAL CARE OF RURAL 
SCHOOL CHILDREN 



BY 

TALIAFERRO CLARK 

Surgeon, United States Public Health Service 



REPRINT No. 366 

FROM THE 

PUBLIC HEALTH REPORTS 

October 6, 1916 
(Pages 2759-2764) 



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WASHINGTON 

GOVERNMENT PRINTING OFFICE 

1916 



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V 



D. of D, 
DEC 9 1916 






THE PHYSICAL CARE OF RURAL SCHOOL CHILDREN.^ 

By Taliaferro Clark, Surgeon, United States Public Health Serivice. 

An officer connected witli the recruiting station of the United 
States Marine Corps, New York City, has been quoted in a recent 
publication^ to the effect that only 316 of 11,012 applicants for 
enlistment in this branch of the public service were up to the required 
physical standard. Furthermore, it has been noted by observers in 
other countries that, in the case of volunteers for military service, 
rejections because of physical unfitness were in direct relation to the 
number of years spent in the school. Although it is not claimed 
that these observations hold true for all sections of the country, they 
do serve to draw attention to the fact that large numbers of indi- 
viduals in the country have not attained the highest individual 
efficiency, and that the schools might be responsible in a measure for 
such lack of development. This is all the more evident when it is 
recalled that the greatest number of rejections for enlistment on 
account of physical defects were due to abnormalities of physical 
development, defective vision and hearing, heart disease, faulty 
teeth, and postural defects. These defects are in a large measure 
preventable, or at least controllable, depending upon their prompt 
recognition during childhood, the period in which so many of them 
have their origin. It is for this reason that the health supervision of 
school children is so necessary. 

Intensive studies of rural school conditions conducted by the 
Public Health Service have revealed a special need of health super- 
vision of rural school children because: (1) They constitute 60.7 
per cent of the total school enrollment of the country; (2) they are 
largely denied the medical attention of specialists such as may be had 
in hospitals and clinics in cities; (3) they can not be protected en 
masse by health laws as is the case in urban communities; and (4) 
they are more unduly affected by endemic diseases which diminish 
vital resistance and exercise an injurious influence on physical and 
mental development, such as malaria, hookworm, and pellagra. 

The needs indicated for the physical care of rural school children 
are quite plain. The first of these is to increase vital resistance 
through measures designed to promote physical development. A 
large proportion of the hampering physical defects observed in later 
life had their origin in childhood, at a period when their early recog- 
nition gives greatest hope of correction. Before these conditions can 

1 Read before the Section on Children, National Conference of Charities and Correction, Indianapolis, 
Ind., May 15, 1916. Reprint from the Public Health Reports, vol. 31, No. 40, Oct. 6, 1916, pp. 2759-2764. 

2 Physical Preparedness. George J. Fisher, M. D. 

66835°— 16 3 



4 PHYSICAL CARE OF RURAL SCHOOL CHILDREN. 

be recognized and corrected, however, it must be known how the 
child grows, what are the laws governing physical development, what 
are the physical averages of the sexes for the different age periods, 
and how these averages are modified by racial and environmental 
influences in different communities. Finally, the school itself should 
be made a place in which the healthy child may grow in a normal 
manner, and where the best development of the weakened child may 
be secured. In this connection we have recently compiled the 
physical averages obtained during an intensive survey by the Public 
Health Service of all the rural school children of Porter County, Ind. 
It was found that the relative physical development of boys and 
girls varied at different ag6 periods. The greatest annual increase 
in height of the boys was between 9 and 10 years of age, 2.5 inches; 
between 14 and 15 years of age, 2.7 inches; and between 15 and 16 
years of age, 2.5 inches. In the case of girls it was between 9 and 10 
years of age, 2.7 inches; and between 12 and 13 years of age, 2.6 
inches. 

The greatest annual increase in weight of boys occurred between 
15 and 16 years of age, 14.8 pounds, and in girls between 14 and 15 
years of age, 10.7 pounds. 

A marked decline in the rate of growth was shown by the physical 
measurements of girls at the 14 and 15 year age periods, which about 
corresponded to the time of the full establishment of the menstrual 
functions. 

Variations in the growth of the child call for great expenditures of 
physical and mental energy at certain age periods. Great care must 
be exercised in the school at this time to maintain correct postures, 
provide suitable exercises and adapt the curriculum to the special 
needs of the child in order to secure the best physical development. 

Compared with the records of children in most urban centers,^ the 
boys of this county were below the average height at the 6 to 7, 7 to 8, 
8 to 9, 11 to 13, 13 to 14, 15 to 16, and 16 to 17 year age periods. The 
girls were under mean height at the 12 to 13, 15 to 16, and 16 to 17 year 
age periods. The deficiency ranged from 0.7 to 2.3 per cent among 
boys and from 0.2 to 2.8 per cent among girls. The weight of boys 
was below the average at the 7 to 8, 9 to 10, 10 to 12, and 14 to 15 
year age periods, and that of the girls at the 7 to 8, 12 to 13, 13 to 14, 
and 15 to 16 year age periods. The deficiency in weight varied from 
0.2 to 5.9 per cent in boys and 0.6 to 8.9 per cent in girls. 

The important consideration in connection with the under physical 
development observed in the rural school population of this county 
was to determine the cause. Malaria and hookworm are not present 
in this community; pellagra is unknown, and there is but a hmited 
prevalence of tuberculosis and typhoid fever. These diseases, there- 

' A Manual of the Diseases of Infants and Children. John Ruhrahj M. D. 



PHYSICAL CARE OF RURAL SCHOOL CHILDREN. 5 

fore, are eliminated as causative factors. On the other hand, our 
observations tend to show that the habitual diet of these children was 
largely responsible. For example, the breakfast of 40 per cent of 
them was composed almost exclusively of carbohydrates, and but 60 
per cent had a mixed diet of carbohydrates and proteids. Further- 
more, 57 per cent used coffee, only 15 per cent drank milk, and 1.16 
per cent did not habitually eat breakfast. The need is plain, there- 
fore, for the general establishment of domestic-science classes in the 
schools and the teaching of food values and food preparation. The 
services of cooperative agencies could also be profitably employed for 
the purpose of extending this instruction to the home. 

Furthermore, no suitable facilities for play were provided and no 
systematic physical exercises were practiced at any of the rural 
schools of the county. The beneficial influences of these on health 
and physical development are now matters of common experience. 
Their absence may account in part for the subnormal physical devel- 
opment of a number of these children. 

Ranking in importance with measures intended to increase vital 
resistance through maintenance of the normal physical development 
of a school child, are those directed to the discovery and correction 
of physical defects. The relative frequency of physical defects 
among rural, as compared to urban, school children, according to our 
observation and the percentages given by Cornell,^ are as foUows: 



Rural. 



Urban. 



Adenoids 

Defective hearing 

Defective teeth: 

6 to 14 years of age 

15 to 18 years of age 

Primary grades 

Grammar grades 

Diseased tonsils 

Refractive errors requiring glasses . 



Per cent. 

11.5 
12.1 

68. 5 to 31. 2 
20. 2 to 16. 1 



Per cent. 

12 to 24 

5 



15.4 
6.7 



50 to 75 

10 to 30 

6 to 12 

28 



Physical defects among rural school children are potentially of more 
serious consequences than those among children in cities. This is 
due to the limited medical facilities in most rural districts and in 
part to poorly constructed and equipped school buildings. Many 
examples illustrative of this observation have come under our per- 
sonal notice. Witness the case of a smaU child between 6 and 7 
years of age who, figuratively speaking, was standing on the edge of 
a threatening volcano, so far as life was concerned, by reason of a 
neglected inflammation of the middle ear. The otoscope revealed a 
slit in a very congested ear drum through which pus was oozing in 
great quantity. Neglect of this condition leads to deafness and not 
infrequently to death. The parents of this child were unaware of its 

1 Health and Medical Inspection of School Children. Walter S. Cornell. 



6 PHYSICAL CARE OF RURAL SCHOOL CHILDREN. 

dangerous condition. Cases like this and many similar cases occur- 
ring in rural schools remain unrecognized through the lack of medical 
supervision untU too late to prevent destructive changes. 

The faulty illumination so frequently observed in rural schools is 
largely responsible for much of the impaired vision encountered. 
Recent measurement of the desk illumination of an eight-room school 
on a cloudy day showed that the illumination of more than half of the 
desks in a number of the classrooms was less than one-third of that 
demanded by the lowest minimum standard. The effect of such 
faulty illumination is to promote eyestrain and to increase near- 
sightedness. The illumination of these classrooms could have been 
doubled by the proper tinting of reflecting surfaces; but the school 
authorities were without competent advice in this important detail of 
school construction. The need of such advice is largely responsible 
for many of the undesirable features of rural school hfe. 

Furthermore, a number of rural school children were badly in need 
of glasses and had never been refracted. The rural school child can 
not step around the comer to an eye clinic and secure the free services 
of a speciahst. These children are frequently found wearing glasses 
entirely unsuited to them, as was a girl with one eye hyperopic and 
the other myopic, who was wearing a farsighted lens in front of the 
nearsighted eye. 

The rural school child is greatly in need of instruction in the care 
of the teeth and in need of adequate dental service. This is shown 
by the fact that 49.3 per cent of the children had defective teeth, 
21.1 per cent had two or more missing teeth, and onh^ 16.9 per cent 
had dental attention. Furthermore, 14.4 per cent of these children 
never used a toothbrush, 58.2 per cent used one occasionally, and 
only 27.4 per cent used one daily. It is now well recognized that 
defective teeth are responsible for a number of the bodily ills which 
materially reduce physical efficiency. Due attention to the care of 
the teeth in childhood wiU prevent their early decay in later life. 
Our investigations have revealed the highest percentage of children 
with defective teeth among boys from the fifth to the eleventh year 
of age, and among girls from the fifth to the tenth year of age. The 
neglect thus evidenced is accounted for by the ignorance of so many 
parents of the necessity of preserving the deciduous teeth as long as 
possible. 

We have collected data relative to the occurrence of communicable 
diseases among rural children while attending school. The compila- 
tion of this material has not yet been completed. Sufficient evidence 
has been adduced, however, to indicate that the school is a factor in 
the spread of these diseases in rural communities, due largely to the 
fact that the children of different families are rarely in intimate 



PHYSICAL CARE OF EURAL SCHOOL CHILDREN. 7 

contact except in school. An undue prevalence of these affections is 
measureably responsible for an increase in the number of children 
with impairment of the organs of special sense. The control of com- 
municable diseases in rural communities is urgently demanded, not 
only in the interests of the general health, but also because they 
endanger vision and hearing. 

The investigations of the Public Health Service show certain 
problems of rural school life which require special consideration. 
For example: What is the remedy for the conditions just enumerated ? 
How can the physical efficiency be increased ? How can hampering 
physical defects be avoided? How is the control of commim.icable 
diseases to be brought about? How is improvement in rural school 
construction to be secured? The answer is (1) by abohshing school 
districts and establishing a county unit of school administration; (2) 
by estabhshing an efficient system of health supervision of school 
children; (3) by consolidating rural schools. 

Of these, measures for the health supervision of school children are 
of prime importance for educational purposes and the protection of 
health. Unfortunately, only a small part of the rural school popula- 
tion of the country enjoys the benefits of such supervision. For 
example, in States where the laws are mandatory for the medical 
inspection of rural schools only 39.8 per cent of the total school enroll- 
ment is in rural districts; where they are permissive, 60 per cent; and 
where inspection laws do not apply, 61.4 per cent. 

There are several reasons for this state of affairs — (1) the lack of a 
proper appreciation of such measures in rural communities; (2) the 
scarcity of persons in rural districts who are properly qualified for 
this service; (3) the financial inabihty of a number of rural com- 
munities to maintain an independent medical inspection service. 

The interest of rural communities in this matter can best be 
secured through intensive school surveys. The value of this pro- 
cedure fies in the fact that, by calling attention to unsuspected 
physical defects in their children and school conditions requiring 
attention, the necessity of some form of health supervision is brought 
home to parents. We have had practical experience of the educa- 
tional value of such investigations through reports of an increased 
number of children seeking refief following surveys of this character. 

The medical inspection of schools in rural districts is accompanied 
by a serious handicap, due to the impossibifity, imder existing con- 
ditions, of securing the services of a person properly quafified for 
this position. The appointment of a local practitioner is, as a rule, 
barren of results. He is unable to devote his whole time to this work, 
while the jealousy and quiet opposition of other local practitioners 
frequently render his efforts nugatory. 



8 PHYSICAL CARE OF RUBAL SCHOOL CHILDREN. 

The requirements of a medical inspector are: (1) He should devote 
his whole time to this service and not engage in private practice or 
other calling that would interfere with proper discharge of the duties 
of tliis position; (2) he should be skilled in medical diagnosis, able to 
refract children for glasses when necessary, and qualified to advise 
with and assist the family physician when it is so desired; (3) he should 
have a thorough understanding of the principles of hygiene and the 
abihty to apply them to school purposes. 

The restricted financial resources of most rural communities pre- 
clude the offering of a salary commensurate with the attainments of 
a desirable school inspector. This difficulty can be overcome, in 
great measure, by combining the duties of the school physician with 
those of the district and the county or local health officer, with a salary 
equivalent to the combined salaries of the two positions. By so 
doing it will be possible for these communities to secure the full-time 
services of a trained sanitarian for health work of which school inspec- 
tion forms a part. The health of the school children is essentially a 
part of the larger problem of the health of the community as a whole. 

The possibility of rural school consoUdation for the protection of 
the health of the children is an important consideration in the adop- 
tion of this measure. The sanitary requirements of school construc- 
tions can more readily be secured in the larger buildings of this type 
and the child thereby placed in a more healthy school environment. 
Furthermore, the concentration of a larger number of children in one 
building offers greater opportunity and facility for health super- 
vision than are afforded by one-room schools. 

Lastly, no system of health supervision will be effective without 
the cooperation of the parents. This can be secured through the 
employment of tactful school nurses to do follow-up work. The 
practical apphcation of the principles of sanitation by an efficient 
nurse in time of sickness wiU do much toward educating parents 
regarding measures for safeguarding the health of their children. In 
addition, the cooperation of social workers and the formation of civic 
leagues and of home and school improvement associations among 
rural school children tend to a better understanding of good citizen- 
ship and of the obligations of the individual to the community, which 
in time should bring about improved social conditions and an 
increased efficiency of the individual. 

o 



